Performs various duties related to transition care planning across the healthcare continuum as directed by Transition Care Coordinator or designee.

Provides specialized patient care coordination and / or departmental coordination. Responsible for the coordination of services / systems in both the inpatient and outpatient settings to ensure an organized, multidisciplinary approach to patient care delivery to achieve identified patient outcomes.

Provides clerical and clinical support to staff in assigned unit.

MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND / OR LICENSURE :

1. High School diploma or equivalent.

2. Graduate of a Medical Assistant Program

3. Obtain certification in Basic Life Support within 30 days of hire date.

PREFERRED QUALIFICATIONS :

EXPERIENCE :

1. Two years’ experience as a Medical Assistant or patient care preferred.

2. Hospital, home health, or payer relations experience preferred.

3. Registration or certification preferred.

CORE DUTIES AND RESPONSIBILITIES : The statements described here are intended to describe the general nature of work being performed by people assigned to this position.

1. Acts as a liaison between patients, physicians / APPs, scheduling, and the multidisciplinary team throughout the healthcare system including inpatient and outpatient environments.

Provides assistance and information to patients, families, and visitors as instructed by the Transition Care Coordinator or designee.

2. Schedules and coordinates hospital discharge follow-up appointments, new PCP appointments, and return appointments. Will use computerized system according to WVU Medicine clinic policy and procedures as applicable.

3. Participates in transition planning activities (e.g. contact of post-acute care facilities, other community resources and transportation) as needed to ensure a timely patient discharge or return to follow-up appointments.

Assists with appropriate linkage with post-acute providers.

4. Provides prompt feedback regarding barriers to transition planning to the Transition Care Coordinator / Designee, enabling them to evaluate / redirect the current patient plan of care in order to streamline the delivery of service.

5. When needed, effectively communicates clinical information with payer to obtain authorization for post-acute services / medications and documents interactions in patient’s electronic medical record (EMR) along with timely communication with Care Management / Clinical staff.

6. Assists the provider / division / multidisciplinary team in quality improvement activities.

7. Coordinates long-term follow-up of patients with their local / referring physicians as needed / directed.

8. Participates in reimbursement, certification and authorization of related activities (e.g. faxing or copying required information) as required.

9. Contacts and coordinates with referral agencies to arrange provision of ordered equipment and associated services when appropriate, as directed by Transition team members or designees.

10. Collects copies and transmits pertinent clinical and patient demographic information required to complete arrangements for post-discharge care and / or placement, as directed by Transition team members or designees.

11. Coordinates and arranges transportation and community services, as directed by Transition team members or designees.

12. Provides secretarial and clerical support, including faxing, copying charts, filing, typing and scanning.

13. Collaborates with financial counselors and social services to assure completion of financial assessments. Assists with making appropriate referrals for patients with limited / no resources.

14. Coordinates, attends, and supports conferences, etc, as appropriate to obtain necessary information for communication with other departments / agencies regarding healthcare needs.

15. Collaborates with inpatient and outpatient multidisciplinary team, as well as post-acute support such as home health services, DME companies, regarding outlined plan of care.

PHYSICAL REQUIREMENTS : The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Prolonged walking, standing, or sitting may be required.

WORKING ENVIRONMENT : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Work is performed across the healthcare continuum, ranging from the inpatient setting to contact and follow-up with the patient via telephone or clinic setting as designated by Transition Care Coordinator Supervisor or designee.

2. Will include patient interaction.

SKILLS & ABILILTIES :

1. Excellent telephone and reception skills.

2. Ability to work collaboratively with health care professionals at all levels to achieve established goals and improve quality outcomes.

3. Basic computer knowledge and ability to operate standard office software.

4. Self-motivated, with proven communications skills.

Last updated : 2024-04-29